9810-085 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class, Exp. Date
114i113 1i
Dat e/Signature of Contract>
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property,'am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(1 OWUN F AC, 1. IS- 11 NS NUIC lill-10"01114to
(This section need not be completed if the permit valuation is for.$100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I.shal fo ith comply wit those• re�'visioo
Date: plicant �"'
Warning: Failure to secure Workers' Compens ' n coverage is unlawful and
shall subject an employer to criminal penaltie�s/and civil fines`up to $100,000, in
addition to the cost of compensation, damages as provided for in Section. 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. ' y 1, i
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such ,
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon a
the above-mentioned property. or inspep'tion purposes. 1„
/S gnature (Owner/Agent) /�� Date �As�C
t l ✓ / !
BUILDING PERMIT PERMIT#
DATE VALUATION LOT -I��-•' TRACT
5147.425.90 r 104
JOB SITE '' ` '
APN
ADDRESS
1,4_145 KNIVE, MURIA
604-371-012
OWNER
CONTRACTOR / DESIGNER / ENGINEER
..°{N'111Y:.S'C:1t07v84.(,t`OItINdiT3`31.";'1S-:i
CEli?'.tf7i:.Y�:Zl1�dl1.,CSa.��.�fil�tt`;Isy
1333 S0. ,.r', 7.l REB , 911718. 11200
1535 SU. "lit` � iR :.1:1:11. S Ml. 42,00
SAN 13E.RNAKOINO CA 9:2405
SAN BEIMARDINO CA 9 408
USE OF PERMIT
G•rar'1•r r.. •r> ;xxr ;- r,,-,r�r x xF,r;-,
'
c• x..x.. J �u _. �� x a asa.. Tsai .
LOT HA - PLAN 46rDR. SIF.D - FiMiii SES i4orwell ,CIGts BLOC
WA.I,LS Oft P.>Qi _PLAN 0iVIX, i•' aF Rrl7L:f W 79A FOR MUL`R`I IL9
1W 1AM0,'r-;S7 irg.A"I?'pi'A-AVTNIT)4
�kC5 COI S�iR Ca l+. N q��F i.11V Or
POW&VA t TO 96.00 S
l3ARAJC:9fi,Ji::A KPf?WE 033.40 i
�ri35i:$.t�Rs;711�.!'t�VYi'�iY' M..bP1:tir:i• 4LraJY,,..Y.IGN
z.
1477 91.1i143
��i 'ai�,�$'l9 T MEE STAIMAkaY
T1,AN(:7w'rC-u FV5 W1 -000439-31R 439-31,R WTM
t+JVC,'HA.-,QCAL REM 101-000-/.121-000 $5150
11LEC'1`€2eCALME IN -400 460 0
krl,.tf�YJ,I3f�Nr„�1+".� � [01•-f}0t}-ti:f.��()00 �±'7Q,'t5
w:T?CiWt'j NFCYI'3.0N MYE - 1101-000-7.414?!(1 !94,'74
Ct/�t.ENC d 33a Y1,CA9.•00r 9x -01)Q 52010
S'RT3�i� `iRl%."E�Ct17E.i" A5400 -44-3-34a $313W.31
AY(T IN PUB13C PL AM 1ESIC 701.000-255.000
�T
0 iMMUCTI N ANN) Pt AN C, CK
t 3= ' TAP
.$,x4.,806 96
.:. � �,.. LrS.� 1,. V. A1D FEES
70,00
DEC 15 1998:�,0�'AIv�t.��r;�
e�.t�ars�3e�t�.�r:,
... . ,tet of
RECEIPT:•
r _ Y
DATE., '
;BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade / /
Return Air
Steel
Combustion Air
Roof Deck fi
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath s
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) —77
COMMENTS: